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			<h3>My Health Risk Factors:</h3>
			<h2>Check the boxes of anything that is true for you:</h2>
			<ul>
				<li>
					<span style="font-weight: bold">Cholesterol Levels: <br/>What are your <a href="#" style="font-size: 15px; font-weight: normal;">cholesterol levels</a>?</span> 				
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					<input type="checkbox" name="chkBxChloesterol1" value="ldl130"/>My Low Density Lipoprotein (LDL): is greater than 130 mg/dL <br/>
					<input type="checkbox" name="chkBxChloesterol2" value="ldl200"/>My Total Serum Cholesterol: is greater than 200 mg/dL <br/>
					<input type="checkbox" name="chkBxChloesterol3" value="ldl40"/>My High Density Lipoprotein (HDL): is less than 40 mg/dL <br/>
					<input type="checkbox" name="chkBxChloesterol4" value="ldl60"/>My High Density Lipoprotein (HDL): is greater than 60 mg/dL<br/>
					<input type="checkbox" name="chkBxChloesterol5" value="lipidMedication"/>I am using a lipid-lowering medication<br/>
					<input type="checkbox" name="chkBxChloesterol6" value="ldlNotKNow"/>I do now know this information <br/>
					<input type="checkbox" name="chkBxChloesterol7" value="ldlNotFit"/>My cholesterol does not fit any of the classifications<br/>
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					<span style="font-weight: bold">Prediabetes: <br/>Do you have impaired <a href="#" style="font-size: 15px; font-weight: normal;">fasting glucose</a>? </span> 				
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					<input type="checkbox" name="chkBxPrediabetes1" value="fasting"/>My fasting blood glucose has been 100 mg/dL  or greater on at least 2 separate occasions<br/>
					<input type="checkbox" name="chkBxPrediabetes2" value="PrediabetesNotKnow"/>I do not know this information<br/>
					<input type="checkbox" name="chkBxPrediabetes3" value="PrediabetesNotFit"/>My fasting blood glucose has been less than 100 mg/dL <br/>					
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					<span style="font-weight: bold">Cigarette Smoking: <br/>Do you smoke?</span> 				
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					<input type="checkbox" name="chkBxSmoking1" value="smoker"/>I am a current cigarette smoker<br/>
					<input type="checkbox" name="chkBxSmoking2" value="quitSmoking"/>I quit smoking within the previous 6 months<br/>
					<input type="checkbox" name="chkBxSmoking3" value="exposed"/>I am exposed to tobacco smoke at home or work <br/>
					<input type="checkbox" name="chkBxSmoking4" value="neverSmoked"/>I never smoked, quick smoking more than 6 months ago<br/>
					<input type="checkbox" name="chkBxSmoking5" value="notExposed"/>I am not exposed on a regular basis<br/>
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				<li>
					<span style="font-weight: bold">Symptoms: <br/>Have you experienced any of the following?  </span> 				
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				<li>
					<input type="checkbox" name="chkBxSymptoms1" value="pain"/>pain or discomfort in the chest, neck, jaw, arms, or other areas that my be due to a myocardial infarction<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="shortness"/>shortness of breath at rest, during activities, or with mild exertion<br/>
					<input type="checkbox" name="chkBxSymptoms3" value="dizziness"/>dizziness or fainting<br/>
					<input type="checkbox" name="chkBxSymptoms4" value="orthopnea"/><a href="orthopnea.html" target="_blank" style="font-size: 15px;">orthopnea</a> or <a href="paroxysmal-dyspnea.html" target="_blank"  style="font-size: 15px;">paroxysmal nocturnal dyspnea</a><br/>
					<input type="checkbox" name="chkBxSymptoms5" value="ankle"/>ankle <a href="#" style="font-size: 15px;">edema</a><br/>
					<input type="checkbox" name="chkBxSymptoms6" value="palpitations"/><a href="palpitations.html" target="_blank" style="font-size: 15px;">palpitations</a><br/>
					<input type="checkbox" name="chkBxSymptoms7" value="claudication"/><a href="intermittent-claudication.html" target="_blank" style="font-size: 15px;">intermittent claudication</a><br/>
					<input type="checkbox" name="chkBxSymptoms8" value="heartMurmur"/>known <a href="heart-murmur.html" target="_blank" style="font-size: 15px;">heart murmur</a><br/>
					<input type="checkbox" name="chkBxSymptoms9" value="fatigue"/>unusual or unexplained <a href="fatique.html" target="_blank" style="font-size: 15px;">fatigue</a><br/>
					<input type="checkbox" name="chkBxSymptoms10" value="notExperienced"/>I have NOT experienced any of the above symptoms<br/>
				</li>
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